Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.

Saturday, January 14, 2012

What We Need

OK, I've gone back through the comments on my last post as well as on Dinah's forced treatment post. I think I've come up with a list of what people have identified as things that need to be added, improved or changed. I'm going to talk to myself in this post, thinking out loud a bit about what each item means to me and how to implement them. Feel free to follow along, add, edit or just ignore me. Like I said, I'm thinking out loud in public.

1. An emergency ear
Even people on an inpatient unit need a crisis contact. A friend to call, an outside volunteer, better access to visitors like family, or a hospital ombudsmen. Patients may not want to or can't access staff, which is a problem. Purposely or unconsciously, inpatient staff discourage patients from approaching them about problems. Patients feel they have no recourse when they are treated poorly or unprofessionally. Some hospitals use after-the-fact patient satisfaction surveys, but personally I'm reluctant to solve a problem by using a form. There needs to be a neutral mediator or ombudsman who is easily accessible to an inpatient. Perhaps allowing an outpatient therapist to hold sessions during a hospitalization would be helpful. (I know there may be financial and bureaucratic issues related to all the items I'm discussing---for the time being let's ignore that. This phase is just outlining the problems and needed solutions.)

2. Professionalism
This item is closely related to item #1. If this item were fixed then item #1 might not exist. What most people may not know is that medical schools recognize this is an issue and now incorporate assessment of professionalism into every medical student and resident evaluation. National professional organizations are also thinking about ways of building this into ongoing licensure processes by requiring physicians to solicit evalutations from their patients. There are also now loads of online 'rate-your-doctor' sites. This is just for physicians, though. I'm not sure how to go about evaluating professionalism for hospital security staff who put someone into seclusion. The psych aides or techs would likely fall into the nursing department realm, and there's no reason there couldn't be a patient feedback loop for that profession as well.

3. Regret
Ah, this is the tricky one. Some commenters said they wished their doctor would have told them that the doctor felt horribly about having to commit someone. Well, when a patient is in crisis it's really not the time to focus on the doctor's feelings. The point is well taken though that mental health providers should be able to talk to the patient afterward about the experience of involuntary treatment, what it was like (for both parties) and ways to avoid it in the future. See item #4.

4. Outpatient crisis plan
I've seen some nursing admission forms that routinely ask patients on admission what they do when they are feeling angry or upset, and what helps them feel better in times of crisis. This almost never involves social connections though, which commenters here say they want more of. This is related to #11, the ongoing discharge plan. Who is in your social support system? Are they helpful are hurtful? Who can you reach most easily? Have you actually used this support system in the past or are you b.s.-ing to get out of the hospital (honesty is going to have to cut both ways, now!)? Hospital lengths of stay are so short now there is almost no purpose to a trial pass or day pass. The general thinking is that if you're well enough for a day pass you must be well enough for discharge. The generic 'return to emergency room' is far from an ideal crisis plan. Perhaps some temporary ongoing outpatient relationship, similar to what internal medicine does: discharge from hospital, to be seen in inpatient doc's own outpatient clinic within X days, until more permanent or preferred outpatient care is arranged.

5. Decent food
Oy, I am the Shrink Rapper with zero food skills. Either of my co-bloggers will confirm that. Nevertheless, it seems evident that medically appropriate, religious or personal preference diets should be available. This one just doesn't seem that complicated, but I don't question that it's a problem.

6. Clean, comfortable environment
Ditto #5. This is one item where patient satisfaction surveys actually could be useful. If month-by-month discharge surveys are all saying you've got bugs in your bathroom, you've got a problem.

7. More autonomy over medications
Pharmacotherapy is always a balancing act between the level of symptoms a patient can live with versus the burden of side effects that they have to carry. I would throw in this thought as well: the people in your support system have to live with your symptoms, too, so they should also be considered. Can we engage family and friends in this balance? If so, how?

8. Meaningful activities
I get this, totally. It's tough when you have an inpatient unit that contains both patients who are so ill they need help bathing and dressing as well as multiply-graduate degreed professionals. William Styron once called occupational therapy 'organized infantilism.' These individualized treatment plans that every team has to fill out should be made useful in some way, and this is where this item should be addressed. What meaningful activities would an educated, high-functioning professional want to do (or feel up to) doing? Most of the units I've worked on have not served many of this kind of patient so I'm open to suggestions here. You also have to address the question: if you're well enough to do (high functioning activity X), do you really need to be in the hospital? That's the question insurance companies will be asking your doctor.

10. Alternative and complimentary treatments
People want things to do besides (or in addition to) taking medication. I'm guessing this means things like emphasizing regular activity or exercise, proper diet, decent sleep but also activities like yoga or tai chi, bibliotherapy (journal keeping, poetry or other writing), music therapy, and so forth.

11. Ongoing discharge planning
I've already covered this a bit, but this would refer to the feeling that people are just dropped outside the door of the unit after discharge with no further contact with the inpatient team. There are already some programs available like day hospitals or partial hospitalization programs, but I don't think this is what people are asking for. I'm thinking more along the lines of returning to the inpatient unit for an "outpatient" visit, if that makes sense, while making the transition to a traditional outpatient practice.

12. Humanize (or de-traumatize) the observation process
This is the last and toughest point. How do you humanely take someone's clothes away while putting them in physical restraints on continuous observation? I know, some people will say this should never be done but that's just not the world I live in. Some people are dangerous when they get sick. Psychiatrists have to make sure everyone in the unit is safe, in addition to protecting the patient. Making sure everyone is trained to recognize and intervene early is important, to prevent seclusion and restraint. Working with the patient early on to identify coping skills and practice those skills, and make sure people on the unit are trained in verbal de-escalation techniques. This won't obviate the need for seclusion in all situations, but it should help minimize its use.

OK, I've spent a fair amount of time thinking about this post, reading old comments, writing and speculating and I'm running out of steam. More later. The last three or four items are going to be the longest, I think. Dinah and Roy, feel free to jump in with your thoughts. This is the stuff of inpatient interviews.

I am a medical student and some of the patients I work with have Psychiatric Advance Directives. These are forms, filled out by the patient, that go into effect if the patient is incapacitated because of psychiatric illness. They can include information such as what medications the patient is willing to take or not willing to take, who is appointed to make health care decisions for the patient, what facilities are acceptable or unacceptable to the patient, which doctors the patient prefers to work with and which doctors the patient does not want involved in his or her care, who will have temporary custody of the patient's children, the patient's dietary and religious requirements, what therapies are preferred and a whole host of other concerns. I think that these can be a very useful tool for both patients and providers to help a patient get the most appropriate care in the event of a crisis. The National Resource Center on Psychiatric Advance Directives provides state-specific information and forms. http://www.nrc-pad.org/component/option,com_frontpage/Itemid,1/

The question is whether involuntary incarceration in a mental hospital should happen at all! A secondary question is whether threats of incarceration should be employed to coerce individuals into taking a medication they don't want or submit to a somatic therapy (ECT)they don't want.

@med student : Involuntary commitment overrides a PAD, (I am familiar with your website which states this clearly.) which incidentally is not at all relevant to poor care. In theory, it prevents hospitalization (again, involuntary commitment, which is the point we are discussing, supersedes that), administration of medication (up for debate) and ECT. There is certainly nothing a PAD can do to mandate humane and respectful treatment.

In an involuntary committment (as well as often in a voluntary commitment) the patient does not have say in which facility is acceptable or not, which doctor he or she would prefer to work with, or prefer not to work with.

It would be lovely if this were true on even a small scale. I think you have most likely as a med student simply not yet been exposed to the reality of inpatient psychiatric care, let alone forced inpatient psychiatric care. Give it a few years.

Anon: I also agree that patients should have access to advocates. I'm not exactly sure what an advocate is, but I am definitely for it.

amduncan: Advanced directives is the way to go. If I'm ever hallucinating, filthy, and living out of a shopping cart on the street, I'd like the right to be treated against my will. And if I'm ever psychotic and planning to kill my children, by all means, I'd like to be put anywhere....

"I'd like the right to be treated against my will" is remarkable for the concentration of inanities and logical inconsistencies in so few words!

Rights aren't things that are granted to you. Rights are things you have already; you can only have them taken away. The so-called 'right to treatment' is no right at all. Rather it is a claim by the government to incarcerate and/or medicate you against your will without due process of law.

If the incarceration is against your will, then by definition you don't want it! It is pointedly ridiculous to claim you want something you don't want (unless you're in analysis, where that kind of thing makes sense.)

The woman who plans to kill her children intends to commit a crime. The State has a legitimate claim to apprehend her. They do not have a claim to apprehend her for her psychosis alone. That's not a crime, right?

A mental health advocate, or patient advocate, is someone that works on behalf of the client, ensuring that the client knows their rights, and that their rights are met and they are treated with dignity and respect. If and when they are not, the advocate can help the patient obtain them, and assist the client in following allowed measures to complain to the hospital higher up about their treatment and convince the hospital to comply. For example, an involuntary patient could have an advocate assist them in obtaining a lawyer with experience in involuntary hospitalization whom may be able to, via the courts, obtain their release. If your dietary needs are not being met and the ward refuses to comply, the advocate could help the client in submitting a complaint; or, if a nurse is being verbally abusive to their patients the advocate can both assist in complaining and follow through with the client to ensure no vindictive responses are had. Sometimes, simply having a knowledgeable witness to your treatment and care can make all the difference in how the staff treat you.

On the flipside, mental health advocates can also assist clients in obtaining mental health services, opening doors that appear to be firmly shut. They can assist you in obtaining disability, help you through any review processes, assist in finding services in your area that can help you when you're in need and your finances suck.

They're basically people that know the system, know how to work within the system, and ensure fairness and basic rights for the clients they are serving.

Still in favor of patient advocates. It sounds expensive. Actually, good food sounds expensive, but I am definitely in favor of that, too. Or at least letting patients order out if they don't like the food.

Rob, sir, I am assuming the possibility that in the course of a psychotic illness, I might not have the insight that I was sick. If I wanted voluntary treatment, I would not check myself into a hospital, I would do this:http://psychiatrist-blog.blogspot.com/2007/01/my-planned-nervous-breakdown.html

But if I don't realize I've lost touch with reality and was in a really bad place, then I'd like to be treated against my will (that will of that moment) at least once, this decision coming from the assumption that I am currently competent but might not be at some moment in the future. I realize that if you are ever psychotic and lacking insight that you don't want to be treated again. Just to be clear here, I don't want to be treated in any of the places our readers describe where they are treated badly. Their stories are miserable. Perhaps I am influenced by the fact that the hospital where I trained was not a hell hole (oh, I believe it's ranked #1 in the country) but I'd much rather be there than in a Baltimore City jail. By the way, if you're psychotic and mention that you want to kill your children, what crime do they charge you with? And how long do they incarcerate you for? And if you're in jail where you've already lost your liberty, is it okay (in Rob world) for the jail psychiatrist to medicate you against your will? And we think they treat vulnerable psychotic people better in jail? Or we call them criminals so we don't care?

Advocates typically work through non-profit organizations, and can either be spanned across the country or specific to individual states. The majority of their cashflow is brought in through fundraising, with your typical charity status exemptions for various state and federal taxes and any other subsidy or break that might be offered. Like most non-profits, some are employed by the company while others volunteer their time and expertise.

The general public doesn't piss and moan so much about crazy-people rights when they're not paying for it outright, and us crazy folk don't piss and moan so much when our rights are upheld. Furthermore, they're most often completely separated from state or federal influence, which makes the clients happy and keeps the critics at bay.

It can be "expensive", but in a way that doesn't place the burden on taxpayers; it's also less expensive in the long run. In many ways, an advocate can also reduce costs, as they connect clients before or after hospitalization to resources that are best fitting to their individual needs, and help the client traverse the system in a more clear and efficient way thereby increasing the success rate of persons with mental illnesses connecting to community services and supports, supports their clients aren't often aware even exist. This can be especially beneficial with the low-income population, the population least likely to receive any support and the most likely to end up in hospital numerous times.

There are already a number of advocacy groups, some state-based and some covering the general population. NAMI and NMHA are two examples of advocacy groups. The problem is, patients aren't provided information on these groups when they arrive at the hospital. There's no guide for the patient at all on what their options are once they've been locked up, and no patient with the slightest bit of their mind left is going to ask the abusive nurse what their rights are.

Advocacy groups are a big thing in most westernized countries, each country's advocacy groups having their similarities and differences (e.g. Canada's main advocacy group serves the community to such a degree that Canadians are often surprised to find out it isn't government-run; UK's Mind is practically the only way to work through the NHS' crappy system). One thing they all do though is advocate for better standards of care for persons with a mental illness.

I don't support forced treatment because it was so damaging to me, but since it exists these are things I think that would at least improve a very bad situation:

1. There needs to be increased accountability. Lack of accountability is one of the biggest problems. Staff in psych hospitals need more people watching their behavior. A lot of the disrespectful treatment, verbal abuse, physical abuse, etc would stop if they knew people with power were watching. Increase the # of unannounced visits by JCAHO in psych hospitals. Give psych patients the same access to friends and family that other patients have. A lot of things said to patients would not be said if family members and/or friends were witness to what is going on.

2. Mail the patient satisfaction surveys after discharge. Satisfaction surveys are worthless when they are used as a condition of release. Nurses will tell patients they cannot leave until they fill them out. When people feel threatened and are still locked inside they will say whatever they feel will help them go home. If it means kissing butt, then that's what they'll do. I found it interesting that other areas of the hospital mailed the patient satisfaction surveys, but the psych ward required patients to fill them out before the door was unlocked and they were allowed to go. Why the difference? Were they afraid of what patients would say when they were no longer under lock and key?

3. Back off. The patient is locked inside and they're safe. If they don't want to go to the silly "what is your goal for the day" group run by a psych tech with a GED, then leave them be. They're not hurting anyone. Continually badgering people who are locked up makes cornered patients feel even more threatened.

4. Fresh air and sunlight. The patient is depressed and is in a depressing environment. Unlock the door and let them go outside and feel the sun on their face and breathe fresh air. This is more helpful for depression than any pill.

5. Regarding meds, no I don't believe family gets to have any input on what the patient takes. I am an adult. I will choose if I want to risk destroying my kidneys with lithium. I took serzone for a year, and now it's off the market because of liver failure. I hope my liver is ok. My family isn't swallowing the pills and accepting the risks of these drugs. I love them, but it's not their place to decide what risks I take with my body.

6. Get rid of the staff who treat patients badly. Do not make excuses for their bad behavior.

7. Stop forcing patients to disrobe in front of staff. Not all psych hospitals do this and they still manage to keep patients safe. This is unnecessary, demeaning and humiliating to patients. You can pat down their pockets if you need to, but don't take away every last ounce of their dignity.

8. I wish there was a way to legislate kindess and compassion as it was sorely lacking in those places, but sadly we can't. That's why we need more accountability, I think it would help.

I appreciate what anonymous has to say about patient advocates. Being hospitalized against your will is frightening enough and a large part of that is not knowing what is happening. The second time I was hospitalized involuntarily I was told I would have to go to court and a judge would decide whether or not to send me to the state hospital...or I could drop out of my doctoral program and move out of state to live with my parents.

I chose to drop out of my program rather than risk the state hospital. Since that time, I have gained a much greater understanding of the laws concerning involuntary commitment and what it takes to get put in the state hospital. If I'd had this knowledge at the time of that hospitalization I wouldn't have felt as threatened by the possibility of facing a judge and who knows...maybe I'd be defending my dissertation this year.

I would love to have had an advocate of some sort...or at least an explanation or a book of some sort about the laws I was up against.

Regarding meaningful activities. I think staff need to quit taking it so personally if a patient doesn't want to do a particular activity. It's not a sign of mental illness that an adult patient refuses to glue a paper doily onto construction paper. Maybe crafts aren't their thing.

As my sister said, if you had been ok with gluing a doily onto contruction paper after having just been forced into a psych hospital, I would have known you had completely given up. Because, that's not you. For someone who enjoys crafts, then that would be a positive sign that they wanted to do crafts. For me, it was very normal that I wasn't interested.

I know I've mentioned this before but in one of the groups they asked us, "If you were an animal in a circus what kind of an animal would you be?" Is this supposed to be helpful? Did they notice the face of that businessman who got admitted for depression? Do they assume that because we have a mental illness and were admitted we all suddenly developed the iq of a cabbage?

We need to replace cookie cutter treatment with looking at what the individual patient needs. Maybe instead of asking the depressed businessman to pretend like he's an animal in a circus, they would have been better off handing him a New York Times to read.

9. I would also like to see mental health care professionals stop using terminology like "peers" to describe patients. For example, my medical record states, "Patient is friendly toward peers." Do they do that to remind patients that they are less than the physician? Or do psychiatrists and therapists do that to try and separate themselves from teh patients, to say hey, I'm not like them.

If you notice other physicians don't feel the need to do that. They just call patients - patients. I have no more in common with the patient who smokes crack than the psychiatrist does. He's not any more or less my peer than he is yours.

You don't hear a pulmonologist describe a patient with COPD talking to his COPD peers.

10. Remember that adult patients are adult patients, and treat them accordingly.

Peers - absolutely. The patients who were acutely psychotic, regular drug users, had spent time in and out of jail, had nowhere to live and had alienated all his family and friends - they were not my peers. We were locked in the same unit, and yes, we felt the same emotions - sad, angry, ehxausted, despair, happy (as did all the shrinks), however beyond that, there were no similarities. Groups talking about anger management and discharge planning simply had no relevance to me as someone with a family, job, profession, life to return to. Case managers and probationary periods simply held no relevance. (And Dinah, this was in the #4 US ranked psych hospital. I'd be shocked if plenty of this didn't happen in your #1, as well.)Actually, I don't care about the language used as long as the staff is aware and capable of differentiating treatment.

Patient advocates -- honestly, should be superfluous. If you have a functional, appropriate, effective system, then you should need advocates only for those too sick to navigate a working system, or who don't speak the language, or who are too severely cognitively impaired to comprehend it. Patients should be treated humanely, effectively, and efficiently. Solve that and you won't need too many advocates except for as they are mostly used, which is a different role then the one described in these comments. In any inpatient unit, you are given a flier with a number of the patient advocacy unit. It is anonymous (supposedly...but what happens if you report abuse while you're there - it's obvious it's you. I mean, really.) and meant for reporting abuse. That is a different role from navigating the psych system and I'm not sure a psych hospital needs to be responsible for that. In theory you have at minimum a shrink and a social worker assigned to handle that. If they did that job, then you're set.

Also, Dinah, I realize you're trying to be flip and funny, but really, please think about what you're saying. You do this often, and the flippancy is not appreciated. you have never been a psych inpatient. You simply don't know. You were a resident, what, 15 years ago? You have no idea what happens. You make a flip comment about "good food" being expensive tantamount to advocates. Dinah, the food is often inedible. We are not talking about gourmet. Nobody is saying, oh, I received a turkey sandwich and I'd rather have a ham sandwich. We're talking simply edible or not. The food I received was foul looking, smelling, and tasting. The fresh fruit was bad. The "snacks" were unhealthy - ice cream, chips, etc - that I don't eat in my regular life and shouldn't be forced to eat in a psych ward. Patients were in theory permitted to keep food on the ward, but not to access it, so it was a moot point, unless a visitor came during the meal time hour -- but wait, those were not visiting hours. Most of the days I was there I ate apples I'd have been better off with airplane meals, and that is not an exaggeration. Perhaps they should cut the shrinks' salaries in order to provide edible food to patients. That would likely cut out some flippancy. Do you think the rest of our concerns are just as unessential or extraordinary as gourmet food?

2) As far as therapeutic activities - go visit any 1st grade classroom in the country. The children are not on the same level. The teachers use something called differentiation to teach the children on their individual levels. Unless the OTs and resident activity supervisors etc are only capable of preparing activities for the lowest functioning people (crayons. glue. smiley face stickers.) which may well be the case (in that case, these psych units need to be reevaluating their staff.....), then the answer is very simple. Prepare say, 3, activities per slot of time per day. High, low and middle functioning. Call them group A B and C if you like. I call it just doing their job. And Clink, being well enough to complete an activity in a psych hospital doesn't mean that the person doesn't need to be there. For example, when I am depressed, my cognition is impaired. I typically read 40-50 pages an hour; depressed, I'm lucky if I can get that far in a week. Does that mean I should stop reading the book I'm in the middle of reading and pick up "Big Bird buys a balloon?" Because that's essentially what you're suggesting. I was severely depressed and unable to keep myself alive, let alone fed, on my own. I was simply not functioning. That's what the hospital did for me. My mind was slowed, but not stopped. And just because it was slow, doesn't mean that I was reduced to a pre-schooler's activities. And there are plenty of people just like me in these units. If these OTs are qualified to work with mentally ill people, they need to do their job, not just pass around the crayons. Like anything, if you put in more work, the result will be better. That there is no accountancy in the the top psych units in the state (and presumably in those lower down), except Dinah's hospital of course, shouldn't be a reason for simply handing out crayons and glue.

And by all means, don't take it personally when I don't want to make a collage with smiley face stickers.

I have appreciated reading the comments here. I identify with a lot of them. I hope that psychiatrists who treat patients in a hospital setting will read the comments here and really stop and think about them.

Please remember that we are you. Just because we've struggled, doesn't mean we're all ignorant. I'm certainly no genius, but I'm no dummy either. Look at all the artists and writers who are much more gifted than I could ever dream of being, who have suffered from crippling depression.

When I tried to explain to my psychiatrist inpatient how it felt to sit in a group and be asked to pretend to be an animal in a circus, he wrote in my medical record that I felt myself too astute for group. I admit, I was noncompliant with pretending to be an animal in a circus. His argument was that psych hospitals play to the lowest common denominator because of lack of funding. Dumbed down groups is all they could afford and patients should just go along and not complain. If you did try and stand up for yourself it was seen as a bad thing.

Here are some suggestions that do not cost any money and would be much more helpful then asking patients to pretend to be circus animals, not taking away of course, from the patients who enjoy being circus animals. After you are through reading your magazines and newspapers, bring them up to the unit when you do your rounds. If a patient is capable of gluing a paper doily onto construction paper or coloring a picture, then a patient is capable of flipping through a magazine. Perhaps the non-crafty types would prefer that instead.

Instead of seeing refusal to attend silly groups, and some of them really are pretty ridiculous, as noncompliance and being bad patients- encourage the things that would be helpful for that particular patient. A card game with other patients, flipping through a magazine, sitting outside in the sunlight, watching a mindless comedy on tv, talking on the phone with a friend, a crossword puzzle or whatever. These things are not expensive.

When I had a lot of bad experiences in the state hospital, I was not there long enough for the state mental health ombudsman to help me. But she did help me file complaints afterwards. She didn't do any of the writing, but she gave me much valuable advice. My worker at the time (not a social worker, but part of social services) said that many patients are very scared of commitment, and so they don't speak up, so the hospital kept getting away with it. The hospital administrator was new at it, and she seemed very upset about what happened, and many changes were made at the hospital because of my efforts. My social worker said that over time, it did seem better for patient, and then the facility closed.

I guess not every state has an ombudsman, or perhaps they are overwhelmed and cannot help much.

Food in a state hospital was NOTHING LIKE food in a community hospital. Regular hospital food is MUCH better. There was little nutritional value - they served cake for breakfast. The cake was good, but it was so strange - I mean, I eat leftover birthday cake for breakfast occasionally, but to serve that in a hospital? Weird.

I wish crisis beds in group homes would be used more. That is much better. You can keep your Ipod and are not searched, and if you go there soon enough, you might not need a hospital. I have been told it saves the county a lot of money. And all the staff were NICE people.

The issue of writing about patients as "peers" is a good example of how some of the issues are a matter of perspective and that there's not an answer that will please everyone. I agree that to compare a group of patients to one another it may be insulting to refer to them as peers (I guess unless they have all won Pulitzer prizes perhaps?) But mental health groups have complained about the term "patient" and patients are now often called clients and consumers (please don't eat me). And these are words, they may influence the staff's attitudes, but no matter what phrase goes into a note, people can still treat others kindly.

Kudos to Ilovecats who complained and got some changes made.

When I was worked on inpatient, awful things sometimes happened. A saw a patient violently break the entire glass enclosure to the unit. In three hospitals where I worked, patients committed suicide (one on a pass home, one upon admission, one shortly after admission---I believe these were all voluntary admissions). In another hospital in town, a patient hung himself in his closet. A resident in my group was assaulted in the ER. Another sent a patient home to have the patient then attack a police officer and get killed. One patient set fire on a unit. Another patient set himself on fire in an outpatient clinic. I think that once something awful happens in a hospital, the hospital becomes a different place, at least for a while, and the trust level of the staff goes down.

This is not to excuse in anyway abusive or unkind or disrespectful practices, or to say the food shouldn't be reasonable and healthy, but to say, if I may, that there may be several perspectives.

And I think the surveys aren't mailed because the response rate would be very very low. You can always write a letter of complaint after your discharge, I wrote about how to do this before in a post called Please Complain, but even then I was told that to spell out how to complain was something everyone knows and so I was being demeaning.

That's because you cease listening to the people who have and are currently experiencing the things you are trying to comment about. Your focus is solely defending your experiences, which sort of makes these posts moot, if you don't want to do much besides that. You do it far more then the other shrink rappers, Dinah.

Nobody here wants to be your patient, but really, if a patient in your office was describing to you the things s/he experienced, would your reply be the same it is?

Don't ask for genuine responses if you aren't really interested in anything other then justifying why your experience 20 years ago justifies current psych unit experiences.

I understand that there are people who do bad things, but we don't force all transplant patients to strip down because one transplant patient shot a doctor. We don't force all family members to strip down to their skivvies because one guy visiting his mom decides to shoot a doctor. We don't require all male psychiatrists to have chaperones present during appointments because a few sleep with their patients.

At some point there has to be some common sense. Forcing depressed patients who have a h/o of having been sexually assaulted to take off their clothes or have them ripped off their body is abusive. Patients aren't saved from suicide by being terrorized.

Honestly, once that had been done to me it didn't matter what food they served or what activities were offered. We were done at that point. My only goal was to get out. I never trusted or confided in the doctor who ordered that done to me. And, I certainly never went back for any follow up.

All I can say is when in distress it's best to be careful that the person you turn to for help shares your views about forced treatment.

Dinah, I had the fortune of listening to a podcast that included one of your colleagues, Dr. Chris Gordon, who is director of this organization, http://www.advocatesinc.org/.

He reminded of the shrink rappers in sharing a passion for being a psychiatrist. But here is what he gets that you all don't seem to.

People have been grievously harmed by psychiatry and that psychiatrists have to keep that in mind when interacting with patients. He didn't do the "yes but" routine that I and others keep hearing from you.

By the way, this is a guy who takes Prozac and jokingly refers to it as Vitamin P. So please do not turn this into an anti psychiatry and meds post because it isn't.

Regarding discussion potential solutions, I applaud Clink for that. But if all you're going to do is talk about it and not lead active follow up efforts to reform the system, what is the point?

You keep suggesting that patient complain about poor treatment but the system needs the folks in power (the psychiatrists) to lead the efforts. Without that, talk is cheap as evidenced by the folks who have posted about horrific situations.

Goodness, this is not an easy conversation. I just put up a post listing twelve points that the Shrink Rappers (pardon me speaking for all of us) agree with you on: we agree this is important, we agree this needs to be fixed, we want to make these things better. Agreement about the problem is the first step.

That said, there are points we likely will never agree on. We probably won't agree that involuntary treatment should never take place. We can still work on improvement even though we don't agree 100%. We can still listen to one another and respect each other's differences.

The Shrink Rappers will present the psychiatrist's side of the story because that's who we are and what we do. We have listened to our commenters, and we hope our readers are also able to consider the issues that psychiatrists must consider.

So actually I have been quite moved by the stories of distressed patients we've read hear over time, and I think you have all convinced us that there is a problem in at least some of the places, some of the time. It's why I continue the conversation (I put up the USA Today article on forced care and making treatment more humane).

I don't believe, however, that every mental health worker is evil and wanting to control people for their own egotistical gain (and neither do most of you). I simply wanted to point out that when something feels wrong, perhaps there is another perspective?

Personally, if someone is violently stripped, I would consider this an assault. Complain. Loudly. Consider pressing charges (they may tell you it's pointless, but I would at least try).

I don't agree that the only change comes from psychiatrists complaining. In fact, I'm sure of it. People here have written in that they have effected change and I applaude them.

And we do believe that some of these situations are awful and egregious abuses. It's probably hard to talk about the really egregious abuses together with the discomforts that should be made better (food, wording) along with the situations that might be a matter of interpretation.

Clink and Roy may be quieter or more sensitive about these issues because they work up close with them. Violence on psych units is not a rare thing, in some hospitals there are hundreds of assaults a year against staff and other patients. Unfortunately, all patients need to initially be checked for contraband, and to be treated as though they may be violent, and this is especially true of involuntary patients (who have been designated an imminent danger). I do believe there are more sensitive ways of handling this then the egregious abuses that some of you are describing.

Three psychiatrists complaining about a system won't work, these complaints are too broad, too varied, and things I have not seen in person. You need to make specific complaints to specific institutions about the people who've violated you. We certainly believe it happens and it's wrong.

1. In addition to availability, patients need to be able to trust that the person to who they can bring complaints isn't just going to take the side of the staff. When the staff present such a unified front against you, it is hard to trust that going to yet another staff member is going to be any different.

3. Would it be so hard or unreasonable for a doctor to say, "I know you really don't want to go to the hospital and I get that. I wouldn't want to go and I don't want you to have go to the hospital, but I don't have any other choices that will keep you safe"?

8. I've had occupational therapy that was in a room well stocked with art supplies and puzzles and the like, but been forced into whatever the chosen activity was. Why not just say, "here is the main activity, you can choose to do something different with what is available." I can make relatively sophisticated art project with the traditionally available tissue paper, glue, and old magazines, so you don't have to corner patients by making them do a particular project unless they want to. It wouldn't be hard to have crossword puzzles, sudoku puzzles, and all sorts of other puzzles available for those of greater ability or differing interests. Books, board games, playing cards, blank paper and pens. Learn from patients. If a patient asks for something that wouldn't be inappropriate, try to get it. Even if you can't have it in time for that patient, you will have more variety for future patients. As for how this demonstrates that these patients aren't sick enough for insurance companies, can you not say, "Yes, she is solving hard sudoku puzzles, but she is also finding ways to hurt herself/hallucinating/refusing to eat/detoxing/etc." If you feel she needs to stay in the hospital despite her sudoku abilities, can you not just tell the insurance company that reason?

Every hospital I've been in has claimed that their treatment is individualized. No hospital that I have been in has actually individualized treatment. When I suggest changes, I am very sensitive to suggesting things that will not make life any harder for the staff. I can only be sensitive to those things I know about. I think about time and difficulty and money and bureaucracy. There is a lot that could be done within those limits that isn't being done. I've tried to ask staff what they would do if they knew that a patient was a genius. What would they do with an Einstein or a Virginia Woolf? So many of my problems come down to my being smarter than the staff, but what if it was confirmed in a generally accepted way like that, rather than having the staff not believe that this mid-20s whippersnapper is really all that smart?

I have long thought that in order to actually change things in mental health care as a patient, I need the sponsorship of a professional. No one is going to let me publish in a professional journal, teach a class of future professionals, or provide pamphlets to patients and their families without that sponsorship. So I am glad we can have this conversation. As for the "yes, but" parts, I've seen few that I can't come up with a totally reasonable solution to. If you refer to patients as peers and can't win because each patient has a different preferred term, let the patient know that when they express a preference. Say you can't promise you will always remember to use their preferred term, but that you will try. Or even just acknowledge their preference and their reasoning, but that you are going to continue to use your term because there is a good argument for every term and you want to maintain consistency.

One poster said this clearly: stop with the "yes but." Dinah, that is what you consisetntly and reliably do with this issue.

anon said this accurately: "6. Get rid of the staff who treat patients badly. Do not make excuses for their bad behavior. "

Dinah, you even "yes but" to this.

Clink took a different stance, validated and encouraged patient opinion while acknowledging there are parts that we will always have difference of opinions. I can hear that.

Dinah, the "yes-but" -ing , psychiatrist must always be right in this situation no matter how horrific - and accurate - the patient's experience was - makes it impossible to hear what you are saying. Why should I bother, when you are not trying to hear what I am clearly stating? I am grateful when I was released from a hospital you were not my psychiatrist. "Yes but" is annoying when between friends, peers, colleagues. It's unacceptable from a psychiatrist, particularly when justifying horrors.

"Three psychiatrists complaining about a system won't work, these complaints are too broad, too varied, and things I have not seen in person. You need to make specific complaints to specific institutions about the people who've violated you. We certainly believe it happens and it's wrong."

Three psychiatrists complaining about a system may not work, but three psychiatrists taking their knowledge and discoveries of flaws within the system into discussions with other psychiatrists can. One psychiatrist has a discussion over coffee with another psychiatrist about how to improve patient care, the second psychiatrist begins to see the problems in his own hospital and finds ways to improve patient care. That psychiatrist talks to another psychiatrist talks to another psychiatrist, and as the message passes down the line the field as a whole can begin to see that desperate change is required within hospitals.

Given that a person within a field is more likely to listen to fellow persons in their field, what you as a psychiatrist say to fellow psychiatrists tends to hold more weight than what we as patients try to explain. We're seen as "not understanding the system", "not having the same perspective". That's part of the point behind your job though, isn't it? Being capable of looking at the world from your client's perspective? Digging deeper? Improving the lives of your clients? And one of the ways that you, as a psychiatrist, can improve the lives of your more hospital-prone clientele is by striving to affect change within the hospital.

Some of the complaints may be vague, but not all, and you have every ability to begin dealing with the ones that aren't so vague. From there, you can narrow down the issues behind the vague complaints and, within your psychiatry circle, define ways to tackle these as well.

Simply saying, "can't be done" is an easy out. Many of these changes can be made if one is willing to stand up and demand change, if they're willing to work at showing others that it is necessary and beneficial. Is it that it "won't work", or is it that you don't want to take on the task of finding ways to make it work?

Anonymous,Please understand that this blog is not about changing anything. it is a way for three psychiatrists to make a bit of extra money on the side from a book that they promote on the site. i think that achieved their goal of monetizing the blog better than Google Ads, but i cannot say by how much. Any reader opinions that are sought help to create new material for the blog but mainly for posts on other web sites which, one would assume, pay a fee per article. Those sites get promoted here too. Be on the watch for the movie, due in theaters next year. Clink and Roy play themselves, Dinah gets Meryl Streep to dye her hair and adopt a New Jersey/Baltimore accent.

It's true that I could have filed a complaint for being forced to strip when I was admitted for major depression. But, it is the policy in many psych hospitals today to do this to patients, and some will even make "voluntary patients" do it. My complaint of abuse would have fallen on deaf ears, because that form of abuse is considered standard procedure in many psych hospitals. I wish it were simply the case of one rogue psychiatrist or one bad psychiatric hospital, but unfortunately this practice is not uncommon.

My plea to psychiatrists is that they recognize the harm of this practice and stop allowing it. Patients who are deeply depressed and have found the courage to turn to someone for help, should not have to leave with additional nightmares.

Some psych hospitals have patients empty their pockets and do not make patients strip. Somehow, those hospitals still manage to keep patients safe. I know of one psychiatrist who actually writes orders for patients not be stripped so I know that the right thing can be done, if only more would follow suit.

I turned to the television news programme BBC Look East because I wanted to voice my complaints about the abysmal care on offer in my last locked acute ward.

The trust chief communications officer tried to undermine me by making a derogatory leak from my medical records. She leaked this information to the BBC journalist.

After that a group of trust psychiatrists tried to detain me. It is very clear from my medical records that this attempted detention occurred because the psychiatrists were unable to tolerate criticism from a service user in the media. The psychiatrist who drew up the form for my detention invented false grounds for making use of the Mental Health Act. She was in a compromised position because I had publicly criticised her ward. She was trying to defend her professional reputation. She was not thinking of my clinical needs. NHS staff should not be using the Mental Health Act as a gag to silence critical service users.

That chief communications officer now no longer works for the trust and the new chief executive has acknowledged to me that her conduct was inappropriate.

So what can we learn from this? The complaints procedure for my local mental health trust does not work at all. To get action I had to go to the BBC and the Care Quality Commission but even now the trust are refusing to debate more specific criticisms of inpatient care at the trust.

I don't think it is possible to have a dialogue with staff at my trust because the moment I open my mouth I am instantly described as "paranoid" in my mental health records and trust staff make no attempt to consider the substance of my complaints. Solution? Go to the media. Seek political allies outside. I don't see any real will to change within the psychiatric profession.

I give my own name because I spoke under my own name when I did that BBC interview. I see many contributions are anonymous and I can understand that but there are advantages in coming out in the open. My position is stronger because I spoke out in public.

HelloI am well qualified to comment on psychiatry and involuntary treatment as I am a much abused victim of psychiatry and also I have read articles by many experts and fellow victims .Here are my experiences/views

1) Nobody as yet understands the brain , the mechanics of mental illness or the mechanics of the so called drugs

2) Keen observers(Robert whitaker etc) have provided statistical evidence that the drugs are not really bebeficial in the long term , but very harmful.

3) The cure rate for schizophrenia is much better in poorer countries like India where you have far fewer psychiatrists , much lesser use of drugs and no "involuntary treatment.

4) psychiatric diagnosis is totally unreliable as has been proved by "Rosenhan Experiment" and can again be proved to be totally unreliable.

5) From my personal experience and experiences of many psychiatric survivors , I can infer that this is a big business for makinf money and it can really devastate you.

So it is obvious we need to challenge the existing mode and do a total review